Urinary Tract Infection (CAUTI) Event Report

Catheter-associated
Patient: IP No: Admit Date:
Diagnosis: Did the patient have diarrhea during time UC was Infection Date:
present? YES______ NO_ _____ Criteria:

Patient’s location/room number(s) and dates patient there:

Microorganism(s) cultured out: Credentials of person inserting UC: RN MD PA APRN NA

Other:
111. 1. Urinary catheter (UC) insertion (date, type, 2. Date UC 3. Length of time 4. # of days between UC insertion
where inserted) Include all re-insertion information if indicated. Removed UC was in (days): and first symptoms of a UTI:

5 Was there a physician order for the Foley? Yes: ______No: _______ If no, please
explain:_________________________________
6 Were alternatives to UC considered and documented? Yes: __________
No: ____ If no, please explain why:______________ ___
7 If the patient experienced urinary retention, was the bladder Yes: __________ Not applicable:___ ____________
scanning protocol followed prior to UC insertion/reinsertion? No: ___________ If no, please explain why:______________________________
8 Did patient meet insertion criteria? Yes: _______No: _____ If no, please explain why UC inserted______________
9 Was catheter secured per hospital policy? Yes: ____No: ____ If no, please explain why
10 Was patient assessed daily for ongoing need for catheter Yes: __________
and did they meet criteria to keep it in? No: ______ If no, please explain
why:________________________________________
11 Was the UC drainage system opened at any point during Yes: __________If yes, please explain:
duration of catheterization? No: _______
12 Did the person who inserted this UC have documented Yes: __________
competency to insert a UC? No: _____ If no, please explain why:________________
13 Was the UC drainage bag kept below level of bladder at all Yes: ____No: _____ If no, please explain why
times?
14 Were there any problems with the UC equipment or Yes: __________If Yes, please explain:___________________________________
supplies? No: ___________
15 Was the patient transported between Yes:_____No:_____ If yes, how was Foley drainage bag transported?
units/Radiology/OR/ED, etc? ________________________________________________________
16 Can each staff member involved in this patient’s care Yes:__________ No:_________ If No, please explain.
verbalize correct strategies to prevent CAUTI?
17 Was the patient and/or family engaged in preventing CAUTI? Yes:__________ No:_________ If No, please explain.
(Did they receive education on the Foley and things they
could do to prevent infection?)
18 Are there any significant patient factors that may have
contributed to this infection? (Elderly, agitated, Yes:__________ No:_________ If No, please explain.
hyperglycemic, etc.)
19 Did workload impact the provision of care? Yes:__________ No:_________ If Yes, please explain.
20 Is the presence of a urinary catheter and date of insertion Yes:__________ No:_________ If No, please explain.
included on all transfer/shift report checklists/protocols?
21 Is there a standard sterile insertion tray available for use that Yes: __________
contains a closed drainage system? No: ___________ If no, please explain why:______________________________
22 What is hand hygiene compliance like for the units in which
the patient stayed?
23 Does each patient have an individual, clean container in Yes: __________
which to empty the UC collection bag? No: ___________ If no, please explain why:______________________________
24 If there is not a nurse-driven protocol to promote catheter Yes:__________ No:_________ If No, please explain.
removal, is there a standard daily reminder to the physician
that the catheter is still in?
25 From the information collected, do you think this CAUTI was Yes:_____ No:________
potentially avoidable? Please explain response:
Urinary Tract Infection (CAUTI) Event Report
Catheter-associated

ISSUE DT : FORM # :

HAI TRACKING FORM

CAUTI Serial no : Date of confirmation:

Patient Registration no (IPD): Ward/ location of patient:

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Brief description of the case:

Noted by RMO/ Ward Nurse/ sign &date :

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Immediate action taken to control spread of infection:

Decided by (Infection control nurse/ RMO) sign / date:

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ROOT CAUSE ANALYSED AND CORRECTIVE
ACTION PROPOSED

TARGET DATE FOR CORRECTIVE ACTION : Analysed by Infection control doctor (sign / date):
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DESCRIPTION OF CORRECTIVE ACTION TAKEN:

Noted by concern Dr. sign / date :

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EFFECTIVENESS VERIFICATION
REMARKS

Head, HICC, sign / date

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